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Full text of "HCFA forms information catalog"

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INI FORMAT ION 



Health Care Financing Administration 

Office of Budget and Administration 
March 1989 






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Health Care Financing Administration 

Office of Budget and Administration 
March 1989 



FOREWORD 

The HCFA FORMS INFORMATION CATALOG is a compilation of the 
•forms produced by the Health. Care Financing Administration to 
manage the Medi care /Med i cai d programs,. The purpose of such a 
catalog sterns from the need to provide a concise and 
up-to-date report of -forms information activity.. Distributed 
by the Office of Budget and Administration, Division of 
General Services,' for use throughout the Department of Health 
a n d H u man S e r v i c e s , t h i s c a t a 1 o g , c o n s i s t i n q o f t hi r e e r e p o r t s , 
is published semi— annually. Monthly supplements ai-B available 
u p o n r e q u e s t „ 

The major reports that comprise the HCFA FORMS INFORMATION 
CATALOG are as follows: Active Forms, Forms Listed by 
Sponsoring Component, and Obsolete Forms. The form numbers 
contained in the r e p o r t s a.r& listed n u m e r i c a 1 1 y . A g 1 o s s a r y 
of the abbreviations and codes used to describe over BOO form 
entries appears as part of this introduction (see Index A). 

The usefulness of the FORMS INFORMATION CATALOG as an 
e f f e c t i v e r e s o u r c e g u i d e is depends n t i n 1 a r g e n \ e a s u r e o r -t 
t i rn e 1 y proce s s i n g of ac c u r a t e a n d complete for m s s t a t u s 
information. U s e r s * of t h i s c a t a 1 o g a r e e n c o u rag e d t o a s s i s t 
us in m a i n t a i n i n g cor r e c t information f o u n d i n t h i s t e x t . T o 
ensure that new information about the status of a form is 
transf erred from the user to the editors of this publication 
in a t i m e 1 y a n d o r g a n i z e d m a n n e r , w e r e c o m mend t h a t s u c h 
infor m a t i o n be s u b m i 1 1 e d t. o t he per s on d e s i g n a ted as t h e 
Bureau Printing and Distribution Liaison Officer (PDLO) . 
Consult Index B for a complete listing of the Central /Regional 
Office PDLOs.. 

To order additional copies of the FORMS INFORMATION CATALOG, 
or to obtain further information about this publication, 
contact the HCFA Forms Management Staff at 966-7863 or 
FTS 646-7363. 



CONTENTS 

FOREWORD 

INDEX A - GLOSSARY OF TERMS AND ABBREVIATIONS ....................... A - 1 

INDEX B -- PRINTING AND DISTRIBUTION LIAISON OFFICERS ................ B - 1 

CHAPTER 1 -- ACTIVE FORMS .............................................. 1 -- 35 

CHAPTER 2 - FORMS LISTED BY SPONSORING COMPONENTS ................... 36 - 109 

CHAPTER 3 - OBSOLETE FORMS .......................................... 1 10 - 141 



A~ 1 



INDEX A - GLOSSARY OF TERMS AND ABBREVIATIONS 



1 . FORM NUMBER 

A number assigned for man a element, control consisting of the 
f a 1 law i n q el e men t s : 



Pref i ;■•; 



A 1 p h a c: h a r a c t e r s s hi o w i n g t. h e r esponsible agen c y ' s 
identic i 



HA- Hearings and Appeals 

l„.j q f :• jq .... |_j s a | +• n rj a r e F inanci n g A d m i n i s t r a t i o n 

HCFAL- Health Care Financing Administration Letter 

SF - Standard Form 



Number- 



The unique set of up to four digits assigned to 
each form; 



yu+ti 



e.g. , 2552 

When indicated, a grouping of up to six 
a 1 p h a / n u m eric s y m b o 1 s d e n o t i n g ; y ear, s e r i e s a n d 
o t h e r s p e c: i a 1 la s e d e s c r i p t :i. o n s „ Ma s t. f r e q u e n 1 1 y 
o c c u r r i n g s p e c i a 1 u s e cod e s a r e ; 



F C -- F o r e i g n C 1 a ims 
INS T -■ I n s t r u c t i o n s 
PR- Puerto Rico 

S S i m p 1 i f :i. e d V e r s i o n 

S C - S e n s o r C o c.i e 
S P -■ S p a n i s h V e r s i o n 
T- Test 
Li- Union 



Construct i on 



A t w o c h a r a c t e r d e s c r i p t i o n d e n o t i n g c o n s t r u c t i o n 
writ t e n i n p a r e n t h e s i s s 



(C) — Computer Pinfeed Version (followed by a 
number denotes page count) 
(CD)- Card 
(BIO- Book 
(F>- Folded 

(FO) Folder 

(LB) Labels 

(PC)- Post Card 

(SEE) --• Set 

<SH>- Single Sheet 

(SM)-- Self Mailer 

(TO- Tab Card 

( T R ) — T r a n s p a r e n c y 

(U) Unit set (followed by a number dencjt.es page 

count ) 



A-2 
INDEX A -- GLOSSARY OF TERMS AND ABBREVIATIONS 



2. FORM TITLE 

The -form's full title (space permitting) or an 
ah ta rev :i. at ed ver s i on r, 

e.g., "HOSPITAL COST DATA". 

3. EDITION DATE 

Indie at es man t h and year o-f usab 1 e ed i t i on r, 

e.g. , 12/84 

4. SPON OFF (SPONSORING OFFICE) 

Current component responsible for text of form; 

BMHA- Bureau of Medicare Hearings and Appeals 

BDMS- Bureau of Data Management, and Strategy 

BERC-- Bureau o-f Eligibility, Reimbursement and Coverage 

B P -- Burea u o f Pro g r a m p e r a t i o n s 

BD.C-- Bureau of Quality Control 

H S Q B -- H e a 1 1 h S t and a r d s a n d Q u a 1 i t y B u r e a u 

A -■ f f i c e o f t h e A d m i n i s t r a t o r 

E -- -f -f i c e o f E x e c u t i v e p e r a t ions 

OACT-- Office of the Actuary 

E< A -- f f i c e o f B u. d g e t a n d A d m i n i s t r a t i o n 

OPHC-- Office of Prepaid Health Care 

OP A-- Of f i c e of Pub I i c Af f a i r s 

R D -- Office o f R e s e a r c h a n d D e m o n s t r a t i o n s 

P R R B ■- P r a v i d e r R e i m b u rse m e n t R e v i e w B oar d 

5. USER 

For- m a u d i e nee; 

A B -- I n t e r m e d i a r y / C a r r i e r 
H ■- H e a d q u a r t e r s 

R r i g i n a t o r of F o r m 

PA-- Part A Intermediary 

P B P a r t B Carrie r 

PC-- Program Service Center 

R - R e g i o n a 1 -f f i c e 

RR— Rai 1 road 

SA~ State Agency 

S S — So c i a I S e c u r i t y 



A-3 



INDEX A - GLOSSARY OF TERMS AND ABBREVIATIONS 

6. SUPPLY SOURCE 

Storage location; 

AUT- Automated form - Electron! cal 1 y transmitted 

i n -for mat i on 

E>OT~- Department o-f Treasury 

FLD- Field Offices 

GSA~ Ben er a 1 Ser vices Ad rn i n i s t r at i on 

HHS— Health and Human Services 

H8S- HCFA Supply System 

LOG- Locally Reproduced 

RGO~ Regional Office 

SPO-- Sponsoring Office 

SSI- Social Security Internal 

SSS- Social Security Supply System 

SSF— Soc i a I Sec u r i t y F i e 1 d Of f ice 

7„ PR I ACT (PRIVACY ACT) 

Forms that collect personal information; 

Y- Yes 
N-- b\o 

B. PUB USE (PUBLIC USE) 

Forms requiring a response from the public and /or 
for" m s u s e d t o info r m t h e p u h 1 i c ; 

Y- Yes 

N- No 

0- EOMB Approved 

9. 0MB NUMBER (EXECUTIVE OFFICE OF MANAGEMENT AND BUDGET 
NUMBER) 

D e n o t e s E x e c u t i v e f f i c e o f M a n a g e m e n t a n d B u d g e t t o 
c o 1 1 e c t i n f o r m a t ion; 

e.g.. , 0938-9999 

10„ EXP DATE (EXPIRATION DATE) 

Date on which EOMB approval ceases; 

e.g. , 8/82 

1 1 . YEAR 0BS0LETED 



o r m 



i nacti vi at;, en ; 



/ /h 



INDEX B - PRINTING AND DISTRIBUTION LIAISON OFFICERS 

REGIONAL PDLOs 



I. 



BOSTON 



II. 



III. 



IV. 



V. 



VI. 



VII. 



NEW YORK 



PHILADELPHIA 



ATLANTA 



CHICAGO 



DALLAS 



KANSAS CITY 



DORA EVERETT 

Room 3.309 

J F K F ederai. B u i 1 d i n g 

Boston, MA 02203 

MAURI CI A ELEBY 

Room 3800 

26 Federal Plaza 

New York, NY 10278 

RICHARD MALESICH 

P.O. Box 7760 

A 1 1 n s A d m i n f -f i c e r 

Philadelphia, PA 19101 

HOWARD VOLLMAR 
Suite 701, Marietta Tower 
101 Marietta Street 
Atlanta, GA 30323 

JERRY GREEN 
HHS/HCFA Region V 
105 Adams, 15th Floor 
Chicago, I L 6 6 4 

SUE KOFAHL 

Room 2400 

1 2 M a i n T o w e r B u i 3. d i n g 

Dallas, TX 75202 

JEWEL BROWNING 

Room 235 

601 East 12th Street 

Kansas City, MO 64106 



FTS 835-1258 



FTS 264-3657 
212-264--3657 



FTS 596-0571 
215-596-0571 



FTS 331-0138 
404 221 224 



pTg 353—3876 

312-353-3689 



FTS 729-6423 
214-7^ 



FTS 758-3539 
816-867-3539 



B---2 



INDEX B 



PRINTING AND DISTRIBUTION LIAISON OFFICERS 



VIII. 



DENVER 



CHARLES WIGLE 

Roam 5 SO 

F e d e r a 1 B u i 3. d i n g 
1961 Stout Street 
Denver, CO 80294 



FTS 564-4024 
303-844-4024 



IX. 



SAN FRANCISCO PAUL PAPAZIAN 

14th Floor 
100 Van Ness Avenue 
San Francisco, CA 94102 



FTS 556-6566 
415-556-6566 



SEATTLE 



ARLETTA BOLES 
HHS/HCFA 

2201 6th Avenue, Mail stop RX-40 FTS 399-0545 
Seattle, WA 98121 206-442-8187 






B-3 



INDEX B - PRINTING AND DISTRIBUTION LIAISON OFFICERS 

HEADQUARTERS PDLOS 

CONTACT 



ORGANIZATION 

OFFICE OF THE 
ADMINISTRATOR <OA> 



SHIRLEY WEBB 



LOCAT I ON 
700 EHR 



TELEPHONE 
6 3151 



PROVIDER REIMBURSEMEN" 
REVIEW BOARD (PRRB) 



GERRI WILLIAMS 



104 PROF 



6-204 1 



OFFICE OF EXECUTIVE 
OPERATIONS (OEO) 



MELISSA STERLING 766 EHR 
RUSTY WILLS 690 EHR 



6 5228 

6-5249 



OFFICE OF PUBLIC AFFAIRS 
CORA) 



MARLYN HARRISON 



305H , HHH 426 8390 



ASSOC I ATE ADM I N I STRATOR 
FOR COMMUNICATIONS (AAC; 



ANITA BRETZFIELD 305H , HHH 



45-6165 



OFFICE OF BUDGET AND 
ADM I N I S T'RAT I ON ( OBA ) 



CHERYL. FUNK 



575 EHR 



OFFICE OF LEGISLATION 
AND POLICY COLP) 



PAUL. IMF: BARNES 



339H, HHti 245-0941 



HEALTH STANDARDS AND 
UUAl.] TY BUREAU CHSQB) 



TERRY CHOLEWCZYNSKI 



6- 67 S3 



OFFICE OF RESEARCH 

AND DEMONSTRATIONS (ORD) 



GERRI MICHAEL DYER l-A-9 DM 



ALICE YOUNG 



l-A-9 OM 



,_.. _., c:r 
{;-, 0-..J / _.' 



«UREAU OF CuALI 

CONTROL (3QC) 



JEANNE FTP MOK- INi.EY 
SUSAN MCCANN 



.r\K 



6 3340 

6-3244 



BUREAU OF PR CUR AM 
OPERA'!' IONS CBPO) 



LINDA KEARNEY 



;•.: K— 4 jvip 



A-- c: ;R90 



REIMBURSEMENT AND 
:OVERAGE (BERG) 



MARIAN KOENIGEBURG 139 EHR 



GLYNIS JOHNSON 



EHR 



u.' •...-■ c 



BUREAU OF DATA 

M A N A G E M E N T A N D S T R A "!" E G Y 



DEBBIE THOMAS 



PHYLLIS 






;v; . a ■;: jvir. 

i p...Q r"iiv| 



6 6123 

6-5368 



.::;.. r ;•; .::.- n:r "(i.-iF' A"!' "' ' r !ri'!\l! :: ■ v 
IV J BOP (OAA) 



RAM POLLARD 



,Q !.:;■ !...:!" 



:.■■■ ! ■'■•■ f..!:\ 



l-l • <; v 






B-4 



ASSOCIATE ADMINISTRATOR 
FOR OPERATIONS (AAO) 



INDEX B - PRINTING AND DISTRIBUITON LIAISON OFFICERS 
HEADQUARTERS PDLOs (cont'd) 

BETTY STANTON 784 EHR 



6-4287 



EQUAL OPPORTUNITY OFFICE 
(EOO) 



LYNN STRANGE 



601 EHR 



6-5515 



OFFICE OF PREPAID HEALTH 
CARE (OPHC) 

OFFICE OF THE ACTUARY 
(OACT) 



HENRIETTA CUNNINGHAM 4360 HHS 

NORTH 



BARBARA FREEBURGER 



100 EQ? 



245-0818 



6-6375 



ASSOCIATE ADMINISTRATOR 
FOR MANAGEMENT (AAM) 



MIKE OBACHOWSKI 
SHERRY CLARK 



742 EHR 
742 EHR 



965-8477 
965-8476 



OFFICE OF BENEFICIARY 
SERVICES (OBS) 



STEVE PUSATERI 



648 EHR 



6-3214 



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XXX 
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I I I I I I I I 
<<<<<<<< 
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IIIIIXIX 



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'U.S. GOUtRNKItNT PRINTING OFF ICE : 1989-24 1 - 1 94 : 051 1 5 



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